Lisa Gierke

An interesting position with a growing company

• INITIAL Only One:
• AA: __
• I have made arrangements for viewing and/or a service to be conducted WITH THE DECEDENT PRESENT PRIOR TO CREMATION with the date and time of viewing or service being:
• Following the above, the crematory will proceed with cremation without obtaining further authorization.
• I request no viewing and / or service for myself or family members, The Crematory is authorized to perform the cremation upon receipt of the human remains, at it's discretion, and according to it's own time schedule, as work permits, without obtaining any further authorization or instructions.

• All personal possessions that I want, have been returned to me and I have been advised that certain items, including but not limited to body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the human remains, will be destroyed or rendered unrecoverable. Further, the Crematory is authorized to separate and remove from the cremation chamber all noncombustible materials, including, but not limited to, hinges, latches, nails, jewelry and precious metals, and to dispose of such materials.
• List any items of value to be delivered to the Crematory along with the Decedent, and provide instructions as to how these items should be handled: __

• PLEASE INITIAL ONE CHOICE ONLY: (TO BE COMPLETED BY INDIVIDUAL ACTING AS HIS OR HER OWN AUTHORIZING AGENT.)
• I do not wish to allow any of my survivors the option of cancelling my cremation and selecting alternative arrangements, regardless of whether my survivors deem a change to be appropriate.
• I wish to allow only the survivor(s) whom I have designated below the option of cancelling my cremation and selecting alternative arrangements, if he or she deems a change to be appropriate.

• I warrant that all representations and statements made herein are true and correct, and that I have read and understand the provisions contained in this document. EXECUTED THIS ____ DAY OF ________________, 20 ____.
• SIGNATURE: ___________________________ PRINT NAME: ___________________________
• ADDRESS: ___________________________ RELATIONSHIP: ___________________________
• CITY/STATE/ZIP: ___________________________ TEL. NO.: ___________________________
• WITNESS SIGNATURE: ___________________________ PRINT NAME: ___________________________

• I certify that: our Funeral Home was responsible for making arrangements with the Authorizing Agent(s), reviewed this form with the Authorizing Agent, and witnessed the above signature of the Authorizing Agent for the cremation of the Decedent. To the best of our knowledge, the above information is true and correct. The human remains delivered to the Crematory and represented as the human remains specified on this form are the human remains that were identified to our Funeral Home as the Decedent, and all viewing and services to be conducted with the body present prior to cremation have been held and the Crematory is free to proceed with the cremation upon receipt of these remains. Our Funeral Home has obtained all necessary permits authorizing the cremation of the Decedent, and those permits are attached.
• F.D. Signature: ___________________________ Funeral Home: ___________________________
• F. D. License No. ___________________________ F.H. City/State: ___________________________

• All cremations are performed individually. Cremation is performed by placing the body, which must be in a leak resistant, rigid container or casket, within the cremation chamber where the temperature is raised to approximately 1100 to 1800 degrees Fahrenheit, and the body will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. The Crematory operator is authorized to open the cremation chamber during the cremation process and reposition the remains of the Decedent in order to facilitate a complete and thorough cremation.
• Upon completion of this cycle, all substances are consumed or driven off, except bone fragments (calcium compounds), metals (including dental fillings of gold or silver), and other nonhuman materials. The cremated remains (consisting of bone fragments, other materials, metals, etc.) are then raked from the chamber. The cremated remains will be separated from metals, which may be affixed to some bone fragments or other human residue, and these materials will be disposed of by the Crematory in a nonrecoverable manner.
• The cremated remains are then mechanically processed (pulverized). Once processed, the cremated remains are then encased in the specified urn. Unless a suitable container is purchased or provided for the cremated remains, the Crematory will place such cremated remains in a container which is designed for short term use. In the event the capacity of the urn or other container is insufficient to accommodate all of the remains of the decedent, the Crematory is authorized to place them in two containers.
• The Crematory makes a prudent effort to remove and recover all of the cremated remains but it is impossible to remove or recover all cremated remains, as some bone particles and other human residue will remain on or within the equipment. It is further impossible to guarantee or warrant that some bone particles or other residue could not possible be commingled with those of previously cremated remains. Pursuant to the authorization on the reverse side, the Crematory may dispose of any such residual particles in any lawful manner it deems appropriate.

• Delivery to the Omega Ltd. Crematory ('hereinafter referred to as the 'Crematory') is accepted on any weekday from 9 A.M. until 4 P.M. We will arrange for night service if necessary.
• Unless previously authorized by the Decedent, in accordance with applicable state law, no cremation may take place without written authorization of the legal representative, or the next of kin, of the Decedent. The next of kin is the person or persons described in the following order: 1. Surviving spouse; 2. Person serving as executor; 3. Decedent’s surviving adult children; 4. Decedent’s surviving parents; 5. Decedent’s surviving siblings; 6. Decedent’s surviving aunts/uncles; 7. Decedent’s surviving first cousins.
• The Crematory reserves the right to reject a cremation container constructed poorly or of noncombustible materials. Metal caskets will be accepted. Plastic, rubber or fiberglass containers will not be accepted. Human remains received in an unacceptable container will be removed prior to the cremation and placed in an acceptable combustible container and the Crematory reserves the right to make disposition of such noncombustible container at its sole discretion. The Crematory is authorized to remove and discard handles or any other items including, but not limited to hinges, latches, nails, jewelry and precious metals, and to dispose of such materials in any lawful manner it deems appropriate. Said removal may prevent damage to the cremation chamber and other equipment.
• Embalming is recommended but not mandatory according to federal law. Human remains may not be cremated until 24 hours after death per Illinois law, or until 48 hours after death per Wisconsin law. A permit from the coroner or medical examiner must be secured prior to cremation.
• Each body will be cremated separately. No unidentified human remains will be accepted for cremation. No human remains over 300 pounds will be accepted for cremation without prior approval and an appropriate rigid container. Absolutely no pets will be accepted for cremation at the crematory. An alternative pet Crematory will be recommended upon request.
• Upon request and with prior notification and appointment, the family may witness placement of the decedent into the Crematory chamber (retort). A licensed Funeral Director must be present. No one will be permitted to witness a cremation in progress. Additional charges may apply.
• Unless given specific written instructions in this Authorization, the cremation, processing and disposition of the remains of the decedent will not be performed in accordance with any particular religious or ethnic customs.
• A minimum of 4 business days for return of cremated remains to the funeral home should be allowed.
• Payment is accepted from a Funeral Home only. Payment in full is expected at the time the service is rendered.